Your contact details

Anything pre-entered above may have been stored as a cookie on your computer to save you re-typing it. We do not use cookies to store any medical or other personal information.

Medical and Psychiatric History

Please answer ✓ "Yes" or ✘ "No" or ? "Don't know" to every question.

1. Have you ever suffered from heart or lung problems?

✔

✘

?

2. Have you ever suffered from liver failure?

✔

✘

?

3. Have you ever suffered from kidney problems?

✔

✘

?

4. Have you ever suffered from a head injury?

✔

✘

?

5. Have you ever suffered from seizures or fits?

✔

✘

?

6. Have you ever suffered from Asthma?

✔

✘

?

7. Have you ever suffered from blood pressure problems?

✔

✘

?

8. Have you ever suffered from balance problems?

✔

✘

?

9. Have you ever suffered from Diabetes?

✔

✘

?

10. Have you ever suffered from pancreas disorders?

✔

✘

?

11. Have you ever had problems of swelling? (E.g. in the stomach or feet)

✔

✘

?

12. Are you allergic to any medication? If yes, please tell us what this is.

✔

✘

?

13. Have you ever suffered from any mental health problems?
If so, please tell us what the problem was/is.

✔

✘

?

14. Have you ever been sectioned under the Mental Health Act?
If so, please tell us when this was and how long you were in hospital.

✔

✘

?

15. Have you ever attempted to harm yourself in any way, for example, taken any overdoses, cutting yourself etc.?
If so please tell us about this.

✔

✘

?

16. Have you ever deliberately attempted to kill yourself?
If the answer to the above question is 'yes' please tell us about this.

✔

✘

?

17. Are you suffering from any medical conditions at the moment?
If so, please tell us about this.

✔

✘

?

18. Are you currently taking any medication?
If so, please tell us which medicines you are taking - what the dose is and how long you have been taking it/them.
N.B. Please include all medications whether prescribed or bought over the counter.

✔

✘

?

19. Have you had a blood test in the last four weeks about which we may contact your doctor?'
If so, please provide the name, phone number and address of your doctor.

✔

✘

?

20. Do you currently use any street drugs, for example, heroin, cocaine, cannabis etc.?
If you are using any non-prescribed drugs you must tell us as this may affect any prescription we may issue you. Please list all non-prescribed drugs here

✔

✘

?

21. Have you ever undertaken a 'detox' for alcohol or drug problems in the past?
If so, please tell us when and where it was, how long ago and what you were detoxing from.

✔

✘

?

22. Approximately how much alcohol are you drinking at the moment?

23. You do not have to tell us but it would be helpful to know who your doctor is.

Name

Phone

Address

24. When did you last see your doctor?

25. Please tick the box if we have your permission to contact your doctor.

26. Please provide the name, age and address of the adult who has agreed to supervise your medication, should you be issued with a prescription.

Name

Age

27. If you are currently being seen by someone from a community drug or alcohol service,
please provide the name, phone number and work address of the staff member.

Name

Phone

Address

28. Today's Date
22nd January, 2019

29. Is the above information correct at the time of completing this assessment?

30. Please confirm that you have read our Service Agreement and agree to the terms and conditions it sets out